Ann Ig 2016; 28: 409-415 doi:10.7416/ai.2016.

2123

“Clean care is safer care”: correct handwashing in the

prevention of healthcare associated infections
R. Squeri1, C. Genovese2, M.A.R. Palamara2, G. Trimarchi 3, V. La Fauci1

Key words: Handwashing, prevention, healthcare associated infections

Parole chiave: Igiene mani, prevenzione, infezioni correlate all’assistenza

Abstract

Background. In 2005, WHO developed the campaign “Clean care is safer care”, aiming at the reduction
of Healthcare Associated Infections (HCAI) through the worldwide promotion of appropriate hand hygiene
practices. Adherence to these practices presently ranges from 5 to 81% (average 40%).
Methods. Aim of the study was the evaluation of healthcare workers (HCWs) adherence to the application
of WHO guidelines on the hand hygiene and the possible impact on HCAI reduction. First, some wards at
highest HCAI risk were identified. Then, direct observational survey was conducted to evaluate the behaviour
of the different HCW categories.
Results. Six-hundred-twenty-eight HCWs were observed: 519 nurses (68 in training), 109 physicians (63 in
training). Survey analysis highlighted that compliance with handwashing was higher in post care practices
(59.6%) than before (55.1%). Some HCWs performed handwashing in both cases. Only in 30.6% of cases
HCWs observed the handwashing technique suggested by the guidelines. In 70.4% they wore gloves during
procedures in which it was possible to have contact with potentially infectious material, but they did not
change them before caring for a new patient in 64% of cases.
Conclusions. The survey confirms the international data, showing a low compliance with hand hygiene
practices by the HCWs and the need to promote a correct handwashing based on respect of the international
guidelines.

Introduction In addition to the damaging effects

Patient safety, i.e. the set of actions aimed
at preventing the avoidable risks arising from
healthcare practices, has become in recent
years an absolute priority for healthcare
settings. Among the most frequently
avoidable risks there are the healthcare-
associated infections (HCAI/HCAIs), which
represent a double public health problem,
associated with the humanization of care
and economic management (1, 2).
on patients’ health, HCAIs will involve
additional therapies, increase assistance
costs and lead to defensive medicine.
In Italy the estimated costs for a single
case range widely, as in United States and
in England (3).
According to a study conducted in 29
European countries by the European Centre
for Disease Prevention and Control (ECDC),
in 2011-2012, HCAI rate in Europe was 6%
of all hospital admissions. In Italy, where

1
Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Italy
2
Postgraduate Medical School in Hygiene and Preventive Medicine, University of Messina, Italy
3
Department of Economics, University of Messina, Italy
410
49 hospitals had been involved, the most
frequent HCAI were found to be those of the
respiratory tract (24% of the total), followed
by urinary tract infections (21%), surgical
site infections (16%) and blood infections
(16%) (4). In Italy HCAIs amount to about
450,000-700,000 per year, causing patients’
death in over 1 percent of cases (5).
The cost, mainly resulting from the
increase in days of hospitalization, can range
from € 4,000 for a patient hospitalized in a
medical ward to € 28,000 for a patient in an
intensive care unit (6).
About 30% of HCAIs are potentially
preventable by adopting effective measures
(1, 7).
The association between hand hygiene and
HCAI onset has been widely demonstrated.
Thanks to the classical studies of Semmelweis
and Holmes (8), this procedure was accepted
as one of the most important measures
for preventing transmission of pathogens
in hospitals and is currently promoted
by the WHO guidelines. Since 2005 the
First Global Patient Safety Challenge is
the reduction of the HCAIs, through hand
hygiene promotion with the campaign Clean
Care is Safer Care.
In 1995 and 1996, in the USA, the
CDC/Healthcare Infection Control
Practices Advisory Committee (HICPAC)
recommended that either antimicrobial soap
or a waterless antiseptic agent be used for
cleansing hands upon leaving the rooms of
patients with multidrug-resistant pathogens,
such as vancomycin-resistant Enterococci
and methicillin-resistant Staphylococcus
aureus (2, 9).
More recently, the HICPAC guidelines
issued in 2002 defined alcohol-based
handrubbing, where available, as the gold
standard for hand hygiene practices in
healthcare settings, whereas handwashing is
reserved for particular situations only (2).
WHO recommends the assessment
of HCWs’ compliance with this practice
through the use of direct and/or indirect
R. Squeri et al.
methods. The direct method, essential to
define precisely the level of hand hygiene
compliance, provides for (a) the observation
of HCWs behaviours by the patients and
the consequent assessment (patients might
feel uncomfortable in having to check the
HCWs’ hygiene compliance) or (b) the
self-assessment by the HCWs. The indirect
methods require to monitor the electronic
control of basins for handwashing and
the cleaning product consumption. The
observational survey collects data on HCWs
anonymously, considering the types of
procedures performed on the patient, the
running time and practice before and after
the use of gloves. Moreover, it was observed
that the awareness of being evaluated
can improve the adhesion of the HCWs
(“Hawthorne effect”), although this effect
can still be reduced (10).
Materials and Methods
The objective of the study, from March
2015 to March 2016, was the evaluation of
HCWs’ adhesion to the application of the
WHO guidelines on hands hygiene and the
possible impact on HCAI reduction. We
performed direct observational surveys in
certain departments at risk, represented
by adult and pediatric intensive care,
general surgery, orthopedics, neurosurgery,
maxillofacial surgery, otorhinolaryngology
and haematology, that were divided into
three areas: surgical, medical and intensive
care. Therefore, we considered the behaviour
of different categories of HCWs with
observation sessions of two hours in each
department at certain times. In each session,
we observed at least 10 opportunities for
handwashing by the operators of each
professional category. 628 HCWs were
observed: 519 nurses (68 in training), 109
physicians (63 in training) belonging to
surgical, clinical and intensive care areas
(Table 1). Looking at the distribution by
Handwashing in the prevention of HAI
Table 1 - Distribution of the subjects by areas
Areas Frequency Percent
Surgical 368 58.6%
Intensive care 154 24.5%
Clinic 106 16.9%
gender, 42.5% were males and 57.5%
females.
Statistic analysis
All statistical variables detected in 628
HCWs have been subjected to synthesis by
frequency distributions. For the verification
of statistically significant differences
between the four HCWs categories (doctors,
nurses, doctors in training and nurses in
training) and all other variables detected in
the sample was used the chi-square test for
k independent samples with their partition
model in the case of rejection of “zero
hypothesis” (11).
The significance of changes in variables
in which each subject is a control of himself
(for example: hands washing pre- vs post-
procedure; use of gloves vs change of gloves)
was tested using the McNemar test (11). For
the purposes of statistical significance, p values
<0.05 were used. All summary and inferential
analyses were performed using R software
(The R Project for Statistical Computing).
Results
The overall adhesion to the handwashing
before and after contact with the patient or
the surrounding environment was found to
be 57%. Overall handwashing adherence
was greater after practicing care (59.6%)
than before contact with the patient (55.1%).
In 30.6% of cases HCWs respected the
handwashing technique envisaged by the
guidelines, while in the remaining cases
(69.4%), they did not follow neither the
timing nor the mode suggested by the
411
guidelines (Table 2). 70.4% of HCWs wore
gloves during manoeuvres in which it was
possible to contact potentially infectious
material, but 64% did not change them
during the switch from one patient to the
next (Table 3). Adherence - with regard to
handwashing before contact with the patient
– was 57.2% for nurses, 56.5% for doctors
and 57.1% for doctors in training (Table 2),
while the lowest adhesion was observed for
nurses in training (38.2%), with statistically
significant differences between this category
and the previous three (χ2 = 8.77; p <0.033).
Similarly for washing after contact with the
patient, the latter category is the one with the
worse adhesion (equal to 44.1%), while the
best adhesion was found for doctors (82.6%)
followed by nurses (60.8%) and doctors in
training (50.8%), with highly significant
differences between categories (χ2=19,15;
p <0.001). An appropriate handwashing was
performed according to current indications
mostly by nurses in training (35,3%: Table
2), followed by nurses, with significant
differences (χ2= 12,43; p <0.006).
The test on the significance of changes
in variables linked to handwashing before
and after patient approach, showed that 282
(44.9%) operators did not wash hands before
treatment and just 72 operators changed their
attitude (25.5% washed their hands in the
post treatment). By contrast, 346 (51.1%)
workers washed hands before treatment
and 44 (12.7%) changed their attitudes, not
washing them in the post treatment. This
change of attitude has some statistically
significant differences (p <0.012).
As regards the use of gloves by nurses
in training, this is the category with greater
compliance (91.2%), with highly significant
differences from the other groups (p <0.001),
followed by nurses (p<0.05) and doctors
(p = 0.997); this practice is not, however,
currently used by doctors in training, who
show adherence equal to 63.5%, with highly
significant differences (p <0.001) with the
other categories. The change of gloves from
412 R. Squeri et al.

Table 2 - Summary table of actions carried out by the four categories

Arms Hand hygiene compliance

Handwashing in Handwashing in Right washing method
pre procedure post procedure
Doctors 56.5% 82.6% 17.4%
Nurses 57.2% 60.8% 33.3%
Doctors in training 57.1% 50.8% 15.9%
Nurses in training 38.2% 44.1% 35.3%
Total 55.1% 59.6% 30.6%

one patient to another is performed by doctors
in most of the cases (82.6%; p = 0.997), but
only in 41.3% of cases by doctors in training,
with highly significant differences from the
other groups (p < 0.001) (Table 3).
In the intensive care area there was a
greater adhesion to handwashing before
the patient approach than in surgical and
clinical wards, with highly significant
differences (χ2 = 115.59, p <0.001). The
same considerations apply for washing
hands after contact with the patient (χ2 =
100.38, p <0.001) and for the adhesion to
handwashing method suggested by the WHO
guidelines (χ2 = 45.21, p <0.001).
Gloves wearing was carried out in 92.2%
of cases by the intensive care operators,
while only 35.8% by clinical area operators
(χ2 = 95.95; p <0.001). Gloves change was
performed in the intensive care units by
89.6% and only by 34 % in the clinical area
(χ2 = 86,03, p <0.001).
In summary, we can say that in 7%
of cases HCWs wore gloves but neither
performed handwashing (both before or
Table 3 - Use and change gloves in the four categories
Change
Arms Gloves worn
gloves
Doctors 82.6% 82.6%
Nurses 67% 64.3%
Doctors in training 63.5% 41.3%
Nurses in training 91.2% 70.6%
Total 70.4% 64%
after contact with the patient), nor the clutch
with hydro-alcoholic gels, and also in 14%
of cases did not adopt any of the actions
required (Fig. 1).
Our study did not suggest greater
adherence of female gender with respect
to male except for changing gloves, which
is carried out mostly by women (69%
versus 31%), with statistically significant
differences (χ2 = 5.47; p <0.02), resulting
from surgical area (χ2 = 5.90; p <0.015) and
ICU (χ2 = 4.63; p <0.031). Sex in the various
categories is evenly distributed.
Discussion and Conclusions
Despite the well established knowledge of
the role of hand hygiene in HCAI prevention,
many HCWs disregarded handwashing in
varying degrees. International literature
reports variable compliance levels, from
5% to 81%, with a mean value of 40% (12-
14). Our study shows insufficient adhesion
with a higher compliance in the ICUs than
in surgery and internal medicine wards,
compared to what has been observed in
other national and in international studies
(15, 16), which report, on the contrary,
more compliance in the surgical and internal
medicine wars than in the ICUs (14, 17).
Overall, the adhesion is lower before the
contact with the patient rather than after
the contact: this involves the need of further
training HCWs; in fact, several studies
Handwashing in the prevention of HAI
Fig. 1 - Type of hygiene by healthcare workers
show an increase in adhesion thanks to
multimodal educational programs (14, 18-
22). The use of gloves was higher than the
national average, even if 31% of HCWs did
not perform handwashing (23). The WHO
guidelines define such action as incorrect,
since the only presence of the gloves
acting as a barrier may not protect from
the transmission of pathogens (24). The
category with the lower adhesion resulted
that of the nurses in training, both before
and after contact with the patient. Low
compliance to hand hygiene is associated
to male sex, to HCWs categories, to use of
gloves, to high workload of the HCWs and,
as previously stated, to work in ICUs (17).
In conclusion, our study revealed a
worrying negligence by HCWs in the
application of the WHO guidelines and the
need for urgent informative and formative
actions. The correct implementation of the
analyzed procedures might bring, in fact,
substantial sanitary, economic and ethical
benefits.
Acknowlegements
Funding: This study did not receive any funding
Competing interest: The authors declare that there are
no conflicts of interest
Ethical approval: Not required.
413
Riassunto
“Cure pulite sono cure più sicure”: il corretto la-
vaggio delle mani nella prevenzione delle infezioni
correlate all’assistenza
Introduzione. Nel 2005 l’OMS ha sviluppato la cam-
pagna “Clean care is safer care”, mirando alla riduzione
delle ICA attraverso la promozione di adeguate pratiche
di igiene delle mani a livello mondiale. L’adesione a tale
pratica varia dal 5% all’81% (valore medio 40%).
Metodi. L’obiettivo dello studio è stata la valutazione
dell’aderenza del personale sanitario all’applicazione
delle linee guida dell’OMS sull’igiene delle mani e il pos-
sibile impatto sulla riduzione delle ICA. Nella prima fase
sono state individuate alcune degenze a maggior rischio
di ICA. Nella seconda fase, è stata realizzata un’indagine
osservazionale diretta per valutare il comportamento
delle diverse categorie di operatori sanitari.
Risultati. Sono stati osservati 628 operatori sanitari
(o.s.): 519 infermieri (68 in formazione), 109 medici
(63 in formazione).Dall’analisi dell’indagine è stata
evidenziata un’aderenza complessiva al lavaggio delle
mani maggiore dopo le pratiche assistenziali pari al
59.6% mentre prima del 55.1% %. Alcuni operatori
sanitari eseguivano il lavaggio delle mani in entrambi i
casi. Solo nel 30,6 % dei casi gli operatori sanitari hanno
rispettato la tecnica di lavaggio delle mani prevista dalle
linee guida. Nel 70,4 % indossavano i guanti durante le
procedure in cui era possibile il contatto con materiale
potenzialmente infetto, ma non li cambiavano tra un
paziente e il successivo nel 64% dei casi.
Conclusioni. Lo studio conferma i dati internazionali,
evidenziando una bassa compliance alle pratiche di igiene
delle mani da parte degli operatori sanitari e la necessità
414
di promuovere un corretto lavaggio delle mani basato sul
rispetto delle linee guida internazionali.
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Corresponding Author: Raffaele Squeri, PhD, Department of Biomedical Sciences and Morphological and Functional
Images, University of Messina, Via Consolare Valeria, 98125 Messina, Italy
e-mail: squeri@unime.it